Medical

Question 1

Enemy casualties are hostile combatants until they:

Answer 1

 Indicate surrender
 Drop all weapons
 Are proven to no longer pose a threat‐ complete body search for weapons and
ordnance, trauma naked if able
 Are removed from reach of weapons
 Are restrained with flex cuffs or other devices

Question 2

Care Under Fire;

No care rendered until-

Answer 2

 TFC phase
 Casualties and scene rendered safe
 Tactical situation permits

Question 3

What should you do in Tactical field care phase management

Answer 3

o Restrain with flex cuffs or other devices if not already done
o Search for weapons and/or ordnance
o Silence to prevent communication with other hostile combatants
o Segregate from other captured hostile combatants
o Safeguard from further injury. Provide care IAW TFC guidelines for US forces after
securing the enemy casualty as described above
o Speed to the rear as medically and tactically feasible

Question 4

Resuscitations under Combat (direct fire) no pulse

Answer 4

 Immediately unresponsive patients with no pulse or respirations, regardless of
cause, should not have resuscitation initiated.

Question 5

Resuscitations under Combat (direct fire) pulse

Answer 5

 Unresponsive patients with a pulse but no respirations should have resuscitation
initiated if it can be accomplished in relative safety.

Question 6

Can Active Duty military members refuse life-saving medical care?

Answer 6

NO

Question 7

What is MARCH PAWS?

Answer 7

A mnemonic device used to cover the vast majority of care required during tactical
field care and tactical evacuation. It covers the care for any trauma patient.

Question 8

Mass Hemorrhage

Answer 8

Visualize and feel (sweep) for life threatening hemorrhage:
 All 4 extremities,
 Then junctional sites (neck, axillae, groins)
 Then torso including back
 Assess pelvic stability
 Treatments: Apply tourniquet, hemostatic gauze, pressure dressing, pelvic
binder, suture/staple, clamp, direct pressure, junctional hemorrhage device,
elevate limb

Question 9

Airway(March)

Answer 9

Look: mouth & neck
 Treatments: clear airway, chin lift/jaw thrust , recovery position, sit up
and lean forward position, NPA, supra‐glottic device, ET tube,
cricothyroidotomy

Question 10

Respirations(March)

Answer 10

Place pulse oximeter
 Look: chest rise and fall, paradoxical motion, chest wall injuries.
 Listen: if possible w/ stethoscope, each side at anterior axillary line.
 Feel: chest wall: ribs and sternum for fractures or tenderness, subcutaneous
18
air, holes or defects.
 Treatments: Apply chest seal, needle decompression, BVM, O2, finger or tube
thoracostomy

Question 11

Circulation(March)

Answer 11

Diagnose shock (declining AVPU, radial/carotid pulse, assess skin, cap refill)
Reassess bleeding control interventions
 Treatment: Hemorrhagic shock: 2x IV/IO; blood or blood products & TXA.
Other types of shock: NS, other

Question 12

Head(March)

Answer 12

Rule out severe intracranial pressure (TBI) by identifying mental status, pupils, posturing or
snoring respirations (Document Glasgow Coma Score on TBI patient)
 Treatment:
1. Keep BP >100,
2. Keep O2 sat >90%
3. 3% saline

Question 13

Hypothermia(March)

Answer 13

Dry patient, insulate from ground, place hat, utilize hypothermia blankets
* While performing the primary assessment, the MARCH interventions are performed when an
indication is found.

Question 14

When should you convert the tourniquet to a pressure dressing?

Answer 14

Limb and junctional tourniquets should be converted to hemostatic or pressure
dressings as soon as possible (or tactically appropriate) unless the patient is in shock, the wound
can’t be monitored for re‐bleeding, or the tourniquet is placed for an amputation.

Question 15

Timing for TQ Conversion?

Answer 15

Less than 2 hours after application is considered safe (attempt conversion)
 2‐6 hours is likely safe, but the upper safe limit has not been scientifically determined
(attempt conversion)
 More than 6 hours requires caution (field conversion not advised due to reperfusion
injuries/kidney failure risk) and management with the crush syndrome protocol

Question 16

What is the procedure of loosening the TQ?

Answer 16

-Add one loose TQ above the original TQ in case the original breaks during conversion.
-Slowly release pressure from the TQ windlass, unwinding a half turn every 10 seconds.Continually monitor for wound bleeding throughout and after conversion. Dress wound
with a pressure bandage.
-If conversion fails and the wound bleeds, move the original TQ as close to the wound as
possible and retighten. If bleeding continues, additionally tighten the extra TQ that is still
in place.
-Attempt the conversion every 10 or 15 minutes if able. Document the number of
attempted conversions,

Question 17

ATMIST? What does it stand for?

Answer 17

Age, Time of Event, MOI, Injuries, Signs and Symptoms, Treatments Performed

Question 18

What is the Combat Shock Protocol (Hemorrhagic Shock)

Answer 18

Dx:
1. MOI and blood loss
2. Declining level of consciousness in the absence of head trauma, or weak/absent radial
pulse
Rx:
3. 2 lines (IV/IO)
4. TXA
5. Blood (whole blood > PRBCs/plasma> PRBC or plasma)
NOTE:
 Start 2 lines. One for blood product, and the other for TXA (1g slow IV push)
 Follow the TXA with another blood product if available
 If using whole blood, give 2 units at a time, if able, until radial pulse/mentation
restored
 If using PRBCs and plasma, give in a 1:1 ratio. If only PRBCs or plasma are available,
give two at a time
 If you do not have IOs, start one IV, push TXA

Question 19

Severe TBI treatment?

Answer 19

Dx:
1. Declining level of consciousness
2. Fixed and dilated pupil(s)
3. Posturing or weakness on one side of body
4. Irregular, snoring respirations
Rx:
1. Prevent hypoxemia (secure the airway)
2. Prevent hypotension ( establish IV/IO access)
3. 250 or 500ml 3% saline
4. Elevate the head 30 degrees if no shock
NOTE: Document GCS and neuro exam.

Question 20

Oro-pharyngeal hemorrhage treatment?

Answer 20

Dx:
1. Massive, uncontrolled bleeding coming from the mouth or throat in a casualty with neck or
facial trauma.
Rx:
1. Procedural IV sedation (Versed 2 mg and Ketamine 100mg) and local lidocaine if
responding to pain and time, tactics and clinical condition permit
2. Cricothyroidotomy
3. Pack the oropharynx with combat gauze‐ leave a tail for each roll outside the mouth

Question 21

Thoracic Trauma Rx?

Answer 21

Dx:
1. Chest trauma
2. Respiratory distress
3. Other physical findings if time and tactics permit
Rx:
Perform these in order until patient experiences relief and improved VS:
1. Needle Decompression (ND) x 2 attempts at 4th or 5th intercostal space (ICS) in the anterior
axillary line
2. Finger thoracostomy and/or chest tube in the 5th ICS in the mid‐axillary line
3. Positive pressure ventilation (BVM, nu‐mask and blow, ventilator)
4. O2 if available

Question 22

Acute Abdomen Rx?

Answer 22

Rx:

1. NPO
2. IV access. NS (normal saline) if medical; or blood and TXA hemorrhagic shock
3. Ertapenem
4. NG tube for PFC
5. Fentanyl for pain
6. Zofran for nausea
7. Acetaminophen PO with sips of water for fever

Question 23

Burns‐ 9, 10, 11, 20, 30

Answer 23

1. TBSA (total body surface area) ‐ there are 11 “9”s. 2 front torso, 2 back torso, 1 each
   upper extremity, 2 each lower extremity, 1 head
2. Use Rule of 10 to start fluid resuscitation (10ml/hr x % TBSA, add 100ml/hr for each 10kg
   above 80 kg)
3. Start fluid resuscitation with LR if >20% TBSA burned
4. Adjust IV fluids to maintain urine output 30‐50 ml/hr
5. Use ketamine for pain
6. Use dry sterile dressings to cover burns. If out > 12 hours debride dead skin once.
7. Put dry gauze between burned digits
8. Perform surgical airway for stridor or respiratory distress (this is generally gradual).
9. Escharotomy PRN for circumferential burns with progressive pain and tension to palpation.
   NOTE: If LR not available, begin fluid resuscitation with NS up to 2‐4 L.

Question 24

Shock: non-hemorrhagic Rx?

Answer 24

1. 1‐2 L of NS, except 250 ml boluses for cardiogenic shock
2. Anaphylactic‐ Epi, Benadryl, Decadron, Zantac (Dx‐ allergic stimulus, red skin, facial
   swelling, respiratory distress, hypotension)
3. Septic‐ Ertapenem, Epi if no response to NS ( Dx‐source of infection, fever)
4. Neurogenic‐ Epi if no response to NS (Dx‐spine trauma, back pain, deformity of spine,
   weakness/paralysis/decreased sensation of extremeties, etc.)
5. Cardiogenic‐ FONA(Fentanyl, Oxygen, Nitro, Aspirin) for chest pain, hold nitro and fentanyl
   for systolic BP < 90

Question 25

What is the acronym used or PFC?

Answer 25

HITMAN

Question 26

(H)itman? Rx? pg 27

Answer 26

Hydration‐ PO/ IV/ IO/ Rectal (PR)/NG tube
 Starting maintenance IVF ‐ rate should be approx 125mL/hr.
 Urine output should be approximately 30‐50 ml/hr at a minimum. Place a Foley in all
patients who are unable to void including all unresponsive patients as well as critical
care patients with burns or in shock
Hygiene‐
 Prevent pressure sores, roll and pad patient q 1‐2 hrs, clean patient q 12‐24 hrs, keep
the patient dry, keep the room clean.
Hypothermia‐
 Take preventative measures; cover casualty to protect from elements and further loss
of heat. If patient is hypothermic, treat per Hypothermia Protocol